Thursday, March 12, 2009

A man who was diagnosed by 11 individual doctors with Multiple Sclerosis was denied disability insurance benefits based on the report of one physician who never even examined him.

Charles Tucker, a man with a wife and two children to support, endured his multiple sclerosis symptoms for two years before reluctantly leaving his job. By that time the tremors and numbness in his hands and feet, as well as his severe headaches, made it impossible for him to perform at work.

Tucker’s neurologist, Dr. Daniel Nieves Quinones, said that the MS “basically disabled him from performing his occupation.”

Although Tucker worried about how his family would make it if he was too sick to work, he was happy that he had been paying for long-term disability insurance coverage from Standard Insurance Company, and filed a claim.

Unfortunately, instead of giving him his benefits, Standard gave Tucker the runaround, claiming that they needed more time and information before they could make a decision on his claim. Frustrated, Tucker retained a lawyer who discovered that Standard was denying his claim based on the opinion of one doctor who had reviewed his medical records, but never examined him. It is not uncommon for insurance companies to hire their own physicians to review claimants’ medical records and write an opinion. However, many consider the doctors who work for insurance companies to be little more than “hired guns” intent on shooting down any claim they can. Montana’s former Insurance Commissioner, John Morrison, said “There’s no question that in certain cases, disability income carriers and health carriers use hired gun physician opinions to deny claims.” Morrison also pointed out that in most states it is perfectly legal for insurers to include “discretionary clauses” allowing them to deny benefits based on one physician’s report, regardless of other medical evidence.

So Tucker, like many other individuals who make the mistake of thinking that just because they pay their premiums they can actually dare to file a claim, seemed to be out of luck from a legal standpoint. Until…Good Morning America did a feature on Tucker, including an interview with Susan Pisano, a spokeswoman for America’s Health Insurance Plans (a group that lobbies for insurance companies). While Pisano defended Standard’s decision and the reputations of insurance doctors, Standard insurance refused speak on camera, and put out a canned statement that the decision in Tucker’s claim was both “fair” and “ethical.”

By strange coincidence, the day after the GMA story, Standard received information from an independent medical review it didn’t have before, and Tucker’s claim was approved after all.

The moral of the story? Check your state laws regarding “discretionary clauses” in insurance policies. If your state allows them, and your policy includes them, you might be better off hiding rainy-day money in your mattress.